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Based on record review and an interview, the hospital failed to ensure the patient/patient representative's right to participate in the development and implementation of his or her plan of care. This deficient practice is evidenced by failing to document the reason the patient did not participate in the treatment plan for 1 (#3) of 3 (#1-#3) patient treatment plans reviewed.
Findings:

Review of hospital's policy titled, "Individual Program Planning, last reviewed 08/2025 revealed in part: PROCEDURE: 4. The patient has the right to be apprised of his or her treatment needs, and to give input into the planning process as a respected team member.

Review of the hospital's policy titled, "Plan of Care", last approved 09/17/2024 revealed in part: POLICY: B. Planning: c. Care plans will be individualized and the patient will be included in negotiating his/her plan of care. d. Documentation of all patient care planning is recorded in the patient's medical record. This will be documented on the Care Plan.

Review of Patient #3's medical record revealed Patient #3 was admitted on 07/25/2025 with Multiple Sclerosis. Patient #3's treatment plan was initiated on admission and updated on 07/29/2025 and 08/05/2025. Further review failed to reveal a patient signature to indicate Patient #3 was involved in their treatment planning.

In an interview on 09/16/2025 at 2:40 PM, S1DON verified there is no documentation Patient #3 was involved in the treatment planning.

Based on observation and interview, the hospital failed to recognize factors related to patient safety and quality improvement. This deficient practice was evidenced by failure to identify potential safety risk of medication storage.
Findings:

During a tour of the facility on 09/15/2025 between 12:00 PM to 12:30 PM, it was observed the medication room with shelves and storage bins. The labeled storage bins revealed items in the storage bins that did not match the bin label.

Bin #1 labeled Tylenol/Motrin/ASA but contained 2 unopened Bottles of D 3 125 mcg containing 110 tablets, 1 unopened bottle of Glucose containing 50 tablets, 1 opened bottle of Thera-M tablets, 2 opened bottles of Sodium Chloride 1 gram tablets, 1 unopened bottle of Aspirin 81mg containing 36 tablets, 1 open bottle of Aspirin 81mg tablets, and 1 open bottle of Vitamin B-1 100mg tablets,
Bin #2 labeled Calcium/Melatonin/Benadryl but contained glucometer lancets
Bin #3 labeled Vancomycin but contained Sodium Chloride inhalation solution 3% 4ml X 60
Bin #4 unlabeled but contained an open bottle of Ammonium Lactate 12% and 1 Fleets enema.
Bin #5 unlabeled but contained Metamucil packets X 16, Albuterol Sulfate Inhaler 90 mcg, and Chloraseptic Lozenges X 4
Bin #6 unlabeled but contained an unopen tube of Hydrocortisone Cream 1%
Further observation revealed the following packaged loose medications found on the shelves in the medication room: Lisinopril 10mg tablet X1, Renal Caps tablet X 1, Dexamethasone 4mg tablet X 1, Sodium Bicarbonate 650mg tablet X 1, and Folic Acid 1mg tablet x1.

In an interview on 09/15/2025 at 12:10 PM, S1DON verified the above information.

Based on record review and interview, the hospital failed to ensure the registered nurse (RN) supervised the care for each patient. This deficient practice is evidenced by:
1)failure to administer medications and treatments per provider order in 1 (#2) of 3 (#1-#3) patient medical records reviewed; and
2)failure to report change in patient's condition to the provider in 1 (#2) of 3 (#1-#3) patient medical records reviewed.
Findings:

1)failure to administer medications and treatments per provider order 1n 1 (#2) of 3 (#1-#3) patient medical records reviewed.

Review of Patient #2's medical record revealed Patient #2 was admitted on 06/25/2025 with Left Foot Amputation with daily wound care ordered on 06/26/2025. Further review of Patient #2's nursing notes revealed daily wound care was missed on 06/27/2025. Patient #2's provider also ordered Tylenol 650mg PO Q 6 hour PRN Temperature > 100 degrees or pain. The following dates and time Patient #2 temperature was > 100 degrees and didn't receive Tylenol: On 07/01/2025 At 8:14 PM temperature was 100.9 degrees; on 07/04/2025 at 8:00 PM temperature was 101.2; and on 07/05/2025 at 9:01 PM temperature was 100.4 degrees.
In an interview on 09/15/2025 at 3:28 PM, S1DON verified Patient #2's nurse didn't follow the MD order for daily wound care or administered Tylenol as ordered.

2)failure to report change in patient's condition to the provider in 1 (#2) of 3 (#1-#3) patient medical records reviewed.

Review of the hospital's policy titled, "Vital Sign Policy" last approved 08/2025 revealed in part: Vital Signs and Sepsis Screening: Reporting and interpretation of vital signs may be used as a screening tool for sepsis. The following vital signs with known or suspected infection should be discussed with Physician/LIP. Temperature >38 or <36 degree Celsius (100.4F or 96.8F).

Review of Patient #2's medical record revealed the following date/times that Patient #2 temperature was > 100.4 degrees that were not reported to the provider: On 07/01/2025 At 8:14 PM temperature was 100.9 degrees; on 07/04/2025 at 8:00 PM temperature was 101.2 degrees; and on 07/05/2025 at 9:01 PM temperature was 100.4 degrees. Further review revealed Patient #2 was transferred to Hospital B on 07/07/2025 and admitted with a diagnosis of Sepsis.

In an interview on 09/15/2025 at 3:35 PM, S1DON verified the above information.

Based on record review and interview, the nursing staff failed to develop and update an individualized plan of care for each patient. This deficient practice was evidenced by failing to update the care plan following an incident for 3 (#1, #2, #3) of 3 (#1-#3) patient records reviewed.
Findings:

Review of the hospital's policy titled, "Plan of Care", last approved 09/17/2024 revealed in part: POLICY: B. Planning: 3. A written Plan of Care is initiated for each patient within 24 hours of admission. b. The Care Plan will be reviewed daily and revised as necessary and as indicated by the changing needs of the patient. c. Care plans will be individualized and the patient will be included in negotiating his/her plan of care. d. Documentation of all patient care planning is recorded in the patient's medical record. This will be documented on the Care Plan.

Review of Patient #1's medical record revealed Patient #1 was admitted on 09/08/2025 with Type 2 Diabetes and Left Foot Ulcer. During Patient #1's hospitalization he received multiple PRN doses of Norco for pain and was taking antibiotics for infection prevention. Further review of Patient #1's nursing care plan failed to reveal a nursing diagnoses for infection prevention or pain management.

In an interview on 09/16/2025 at 3:40 PM, S1DON verified Patient #1's nursing care plan should have addressed infection prevention and pain management.

Review of Patient #2's medical record revealed Patient #2 was admitted on 06/25/2025 with Left Great Toe Amputation. Review of Patient #2's nursing care plan failed to reveal an update to the actual/potential for infection related to wound nursing diagnosis when the provider ordered a wound culture on 07/07/2025 and placed Patient #2 on IV antibiotics on 07/07/2025.

In an interview on 09/15/2025 at 4:00 PM, S1DON verified the above information.

Review of Patient #3's medical record revealed Patient #3 was admitted on 07/25/2025 with Multiple Sclerosis. Review of Patient #3's nursing care plan failed to reveal any updates for diagnosis Actual/Potential for Infection related to Foley Catheter, Self-Cath when Patient #3 was diagnosed with an UTI and placed on Antibiotics. Patient #3 also received multiple PRN medications for pain during hospitalization and Pain was not addressed on the Nursing Care Plan.

In an interview on 09/16/2025 at 2:35 PM, S1DON confirmed the above mentioned information.

Based on record review and interview, the hospital failed to follow its policy and procedure to ensure that medical records were completed within 30 days of discharge in 1 (#2) of 3 (#1-#3) patient medical records reviewed.
Findings:

Review of Patient #2's medical record revealed admission on 06/25/2025 and discharge on 07/07/2025. Further review revealed a discharge summary initiated on 08/06/2025 at 11:09 AM, but not signed by the provider as of 09/16/2025.

In an interview on 09/16/2023 at 2:50 PM, S1DON verified the discharge summary was not signed by the provider within 30 days from Patient #2's discharge date of 07/07/2025.

Based on observation and interview, the hospital failed to ensure all drugs and biologicals were kept in a secure area. This deficient practice is evidenced by failing to lock the medication room door.
Findings:

During a tour of the facility on 09/15/2025 at 12:00 PM, the medication room door was unlocked and propped open leaving medications unsecure. Observation in the medication room included unlocked medication bins with patients' prescription medications and the unit's OTC medications.

In an interview on 09/15/2025 at 12:10 PM, S2DON verified the medication room door should not be propped open and should be locked to secure the patient's prescription medications and the unit's OTC medications.

Based on observation and interview, the facility failed to ensure expired and unusable drugs and supplies were not used for patient care. The deficient practice is evidenced by the presence of unlabeled bags of discontinued medications from previous patients.
Findings:

During a tour of the facility on 09/15/2025 at 12:00 PM, the medication room door was unlocked and propped open leaving medications unsecure. Observation in the medication room included a large plastic bin on the floor with overflowing plastic bags filled prescription medications. Further inspection revealed one of the plastic bags were Patient #4's prescription home medications. Patient #4 had been discharged from the facility since 08/01/2025 and not returned or discarded.


In an interview on 09/15/2025 at 12:15 PM, S1DON verified that pharmacy is supposed to pick up discontinued medications weekly. S1DON confirmed there should not be discontinued medications from patients who were discharged in August 2025.